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Medical Nutrition Therapy in Cardiovascular Disease Chapter 35.

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1 Medical Nutrition Therapy in Cardiovascular Disease Chapter 35

2 © 2004, 2002 Elsevier Inc. All rights reserved. Coronary Heart Disease (CHD) or Coronary Artery Disease (CAD) n Disease involving the network of blood vessels surrounding and serving the heart n Manifested in clinical end points of myocardial infarction (MI) and sudden death n Disease involving the network of blood vessels surrounding and serving the heart n Manifested in clinical end points of myocardial infarction (MI) and sudden death

3 © 2004, 2002 Elsevier Inc. All rights reserved. Cardiovascular Disease (CVD) n CVD has been the leading cause of death in the United States for every year since 1900, except n CVD kills almost as many people yearly as the next seven causes of death combined. n CVD has been the leading cause of death in the United States for every year since 1900, except n CVD kills almost as many people yearly as the next seven causes of death combined.

4 © 2004, 2002 Elsevier Inc. All rights reserved. Prevalence and Incidence n The United States ranks 14th and 16th, among industrialized nations for the prevalence of CVD in women and men, respectively. n More than 61 million Americans have at least one form of CVD (i.e., hypertension, CHD, stroke, rheumatic heart disease, or congestive heart failure). n The incidence of CHD is high; an American experiences a coronary event almost every 29 seconds. n The United States ranks 14th and 16th, among industrialized nations for the prevalence of CVD in women and men, respectively. n More than 61 million Americans have at least one form of CVD (i.e., hypertension, CHD, stroke, rheumatic heart disease, or congestive heart failure). n The incidence of CHD is high; an American experiences a coronary event almost every 29 seconds.

5 © 2004, 2002 Elsevier Inc. All rights reserved. Natural Progression of Atherosclerosis (From Harkreader H. Fundamentals. Philadelphia: W.B. Saunders, 2000)

6 © 2004, 2002 Elsevier Inc. All rights reserved. Plaque That Has Been Surgically Removed from Coronary Artery Courtesy Ronald D. Gregory and John Riley, MD.

7 © 2004, 2002 Elsevier Inc. All rights reserved. Prevention n Blood lipids and lipoproteins n Total cholesterol n Total triglycerides n Lipoproteins and metabolism —Chylomicrons, VLDL, IDL, LDL, HDL n Blood lipids and lipoproteins n Total cholesterol n Total triglycerides n Lipoproteins and metabolism —Chylomicrons, VLDL, IDL, LDL, HDL

8 © 2004, 2002 Elsevier Inc. All rights reserved. Functions of the Plasma Lipoproteins n Chylomicron—Transport of dietary triglyceride n VLDL—Transport of endogenous triglyceride n IDL—LDL precursor n LDL—Major cholesterol transport lipoprotein n HDL—Reverse cholesterol transport n Chylomicron—Transport of dietary triglyceride n VLDL—Transport of endogenous triglyceride n IDL—LDL precursor n LDL—Major cholesterol transport lipoprotein n HDL—Reverse cholesterol transport

9 © 2004, 2002 Elsevier Inc. All rights reserved. Lipoprotein Assessment n Includes measurement of total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride level after fasting

10 © 2004, 2002 Elsevier Inc. All rights reserved. Cardiovascular Risk Factors n Category I—cigarette smoking, LDL cholesterol, high-fat diet, hypertension n Category II—diabetes mellitus, physical inactivity, HDL cholesterol, TG, obesity n Category III—psychosocial factors, lipoprotein a, homocysteine n Category IV—age, male gender, low socioeconomic status, family history n Category I—cigarette smoking, LDL cholesterol, high-fat diet, hypertension n Category II—diabetes mellitus, physical inactivity, HDL cholesterol, TG, obesity n Category III—psychosocial factors, lipoprotein a, homocysteine n Category IV—age, male gender, low socioeconomic status, family history

11 © 2004, 2002 Elsevier Inc. All rights reserved. Quantity of Soluble Fiber Needed Daily to Produce Lipid-Lowering Effect n Pectin: 6 to 40 g n Gums: 8 to 36 g n Dried beans or legumes: 100 to 150 g n Dry oat bran: 25 to 100 g n Oatmeal: 57 to 140 g n Psyllium: 10 to 30 g n Pectin: 6 to 40 g n Gums: 8 to 36 g n Dried beans or legumes: 100 to 150 g n Dry oat bran: 25 to 100 g n Oatmeal: 57 to 140 g n Psyllium: 10 to 30 g

12 © 2004, 2002 Elsevier Inc. All rights reserved. Genetic Hyperlipidemias n Familial hypercholesterolemia n Familial combined hyperlipidemia n Familial dyslipidemia n Familial dysbetalipoproteinemia n Familial hypercholesterolemia n Familial combined hyperlipidemia n Familial dyslipidemia n Familial dysbetalipoproteinemia

13 © 2004, 2002 Elsevier Inc. All rights reserved. Nutrient Composition of the Therapeutic Lifestyle Change Diet n Saturated fat n Polyunsaturated fat n Monounsaturated fat n Total fat n Carbohydrate n Saturated fat n Polyunsaturated fat n Monounsaturated fat n Total fat n Carbohydrate n Fiber n Protein n Cholesterol n Total calories (energy)

14 © 2004, 2002 Elsevier Inc. All rights reserved. Category I Risk Factors for Coronary Heart Disease n Cigarette smoking n Elevated LDL and total cholesterol n Hypertension n Left ventricular hypertrophy (LVH) n Thrombogenic factors n Cigarette smoking n Elevated LDL and total cholesterol n Hypertension n Left ventricular hypertrophy (LVH) n Thrombogenic factors

15 © 2004, 2002 Elsevier Inc. All rights reserved. Category II Risk Factors for Coronary Heart Disease n Diabetes mellitus types 1 and 2 n Physical inactivity n Low HDL cholesterol n Obesity n Menopausal factors n Diabetes mellitus types 1 and 2 n Physical inactivity n Low HDL cholesterol n Obesity n Menopausal factors

16 © 2004, 2002 Elsevier Inc. All rights reserved. Major Disease Processes Contributing to Coronary Heart Disease n Atherosclerosis—chronic (long-term development) n Thrombosis—acute (late and brief event) n Atherosclerosis—chronic (long-term development) n Thrombosis—acute (late and brief event)

17 © 2004, 2002 Elsevier Inc. All rights reserved. Pathophysiologic Steps in Development of Coronary Heart Disease/Myocardial Infarction Phase 1Fatty streaks (atherogenesis) Phase 2Atheroma (or plaque) formation Phase 3Complicated lesions with rupture (nonocclusive thrombosis) Phase 4Complicated lesions with rupture and occlusive thrombosis Phase 5Fibrosis (occlusive) lesions Phase 1Fatty streaks (atherogenesis) Phase 2Atheroma (or plaque) formation Phase 3Complicated lesions with rupture (nonocclusive thrombosis) Phase 4Complicated lesions with rupture and occlusive thrombosis Phase 5Fibrosis (occlusive) lesions

18 © 2004, 2002 Elsevier Inc. All rights reserved. Hyperlipidemias n Elevated blood triglycerides and/or cholesterol n Lipoproteins found in blood n Chylomicrons = postprandial dietary fat n Very-low-density lipoproteins (VLDL) = lipid being transported from liver to peripheral tissue n Low-density lipoproteins (LDL) = transport of cholesterol n High-density lipoproteins (HDL) = reverse transport of cholesterol, tissues to liver n Type of hyperlipidemia depends upon portion of particles present n Elevated blood triglycerides and/or cholesterol n Lipoproteins found in blood n Chylomicrons = postprandial dietary fat n Very-low-density lipoproteins (VLDL) = lipid being transported from liver to peripheral tissue n Low-density lipoproteins (LDL) = transport of cholesterol n High-density lipoproteins (HDL) = reverse transport of cholesterol, tissues to liver n Type of hyperlipidemia depends upon portion of particles present

19 © 2004, 2002 Elsevier Inc. All rights reserved. LDL and HDL Cholesterol Laboratory Values Predict Risk of CHD n LDL-C >130 mg/dl n HDL-C <35 mg/dl n Total cholesterol (TC) >200 mg/dl n Total triglycerides (TG) >150 mg/dl n Formula: LDL-C = TC – HDL-C–(TG/5) n LDL-C >130 mg/dl n HDL-C <35 mg/dl n Total cholesterol (TC) >200 mg/dl n Total triglycerides (TG) >150 mg/dl n Formula: LDL-C = TC – HDL-C–(TG/5)

20 © 2004, 2002 Elsevier Inc. All rights reserved. HDL Cholesterol Levels Predict Risk of Coronary Heart Disease n Increased by: Exercise Weight loss Moderation of alcohol n Decreased by: Obesity No exercise Cigarettes Androgenic steroids B blockers High TGs Genetic factors n Increased by: Exercise Weight loss Moderation of alcohol n Decreased by: Obesity No exercise Cigarettes Androgenic steroids B blockers High TGs Genetic factors

21 © 2004, 2002 Elsevier Inc. All rights reserved. LDL Cholesterol Levels Predict Risk of Coronary Heart Disease n Increased by n Fat in diet n Obesity n Diabetes n Hypothyroidism n Decreased by n Estrogen n Increased by n Fat in diet n Obesity n Diabetes n Hypothyroidism n Decreased by n Estrogen

22 © 2004, 2002 Elsevier Inc. All rights reserved. Primary Prevention with Lipoprotein Analysis (From National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). National Institutes of Health, NIH Publication No Bethesda, MD: National Heart, Lung, and Blood Institute, 1993.)

23 © 2004, 2002 Elsevier Inc. All rights reserved. Primary Prevention in Adults without Evidence of CHD: Initial Classification Based on Total Cholesterol and HDL Cholesterol (From National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). National Institutes of Health, NIH Publication No Bethesda, MD: National Heart, Lung, and Blood Institute, 1993.) HDL = high-density lipoprotein.

24 © 2004, 2002 Elsevier Inc. All rights reserved. Diet Therapy for High Blood Cholesterol (Data from National Cholesterol Education Program [NCEP]. Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel II]. NIH Publication N Bethesda, MD; National Institutes of Health. National Heart, Lung, and Blood Institute, 1993.) * Calories from alcohol not included.

25 © 2004, 2002 Elsevier Inc. All rights reserved. General Goals for Treatment of Hyperlipidemias n Achieve IBW. n Decrease simple sugars and alcohol. n Decrease total fat, especially cholesterol and SFA. n Increase complex carbohydrate and fiber. n Achieve IBW. n Decrease simple sugars and alcohol. n Decrease total fat, especially cholesterol and SFA. n Increase complex carbohydrate and fiber.

26 © 2004, 2002 Elsevier Inc. All rights reserved. Lipid-Lowering Drugs Added if Diets Are Not Successful n After a 6-month trial on each diet, drugs are added to the treatment. n Types: n Nicotinic acid and lovastatin n Gemfibrozil, probucol, clofibrate— for high TGs n Cholestyramine and colestipol (bile acid sequestrants)—to lower high cholesterol; may increase TGs n After a 6-month trial on each diet, drugs are added to the treatment. n Types: n Nicotinic acid and lovastatin n Gemfibrozil, probucol, clofibrate— for high TGs n Cholestyramine and colestipol (bile acid sequestrants)—to lower high cholesterol; may increase TGs

27 © 2004, 2002 Elsevier Inc. All rights reserved. Myocardial Infarction (MI) Coronary Infarction, Coronary Thrombosis, or Heart Attack n Some part of coronary circulation blocked n Ischemia leads to muscle destruction n Diagnosis: ECG; blood levels of enzymes such as LDH and CPK n Some part of coronary circulation blocked n Ischemia leads to muscle destruction n Diagnosis: ECG; blood levels of enzymes such as LDH and CPK

28 © 2004, 2002 Elsevier Inc. All rights reserved. Myocardial Infarction—MI Postinfarction nutrition 1.1st 24 hrs: no caffeine, liquid diet (nausea and choking are common) 2.Small frequent meals; soft or liquid diet 3.Na + restriction if BP and fluid status indicate 4.Consistent diet information 5.Drugs that cause nausea—digitalis,morphine Postinfarction nutrition 1.1st 24 hrs: no caffeine, liquid diet (nausea and choking are common) 2.Small frequent meals; soft or liquid diet 3.Na + restriction if BP and fluid status indicate 4.Consistent diet information 5.Drugs that cause nausea—digitalis,morphine


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